The Tower of Babel: Are Indian doctors in the Health Ministry’s Crosshairs?

First, it was at the Mint. Then, I caught it at India Ink with an error to boot. Then, a war of opinions started on Twitter. All of it a big storm in a tiny teacup.

The Indian Government (GOI), through its Minister of Health Mr. Ghulam Nabi Azad, announced yesterday that, from this year on, Indian doctors who planned to pursue medical training in the US would first need to sign a government bond that would enforce their return to India upon the completion of the training period. The minister said that this initiative was a reactionary response to a specific US demand that Indian doctors must be in possession of an NOC (No Objection Certificate) from GOI. He further stated, that non-compliance would force GOI to revoke the NOC which action, would automatically prevent the doctor from practicing his trade in the US.

The glaring logical and legal gaps in this position are stark enough to have given the matter a quiet burial. Instead, what followed was a flurry of writing and debate in both mainstream and social media. In the ensuing cacophony of interpretations and assumptions whatever little was understood, of government-speak, was further mangled. It is perplexing that a simple clarification of the issues (from doctors) and of the statement (from the ministry) was not sought. In the absence of such an explanation and because the subject of medical education and licensing is frustratingly complicated (worldwide), a detailing of some of the underlying issues seems necessary.

The degree:

India: Indians, upon graduation from med school, are conferred an MBBS. After this basic degree, an additional three year training in a specific subject, confers on them an MD/MS. Beyond this there are two year courses, referred to as super/hyper-specialization programs, which confer the DM/MCh degrees. All these degrees can only be obtained after training in a medical college. Since the demand for any of the post-MBBS degrees is huge, GOI set up the National Board which confers the DNB degrees. These are ‘MD equivalence’ degrees, that are offered by ‘private hospitals’ (not medical colleges) under the aegis of the Universities.

US: The basic medical degree is itself an MD. An MD therefore is typically equivalent to an MBBS. The difference: All MDs in the US are guaranteed training in a specialty of their choice. The demand-supply is perfectly met with a deficit on the ‘demand’ side (demand here refers to the market need for doctors), which provides the portal of entry for foreign medical graduates (FMGs). This training is called a Residency and is equivalent to the Indian MD. Onl,y that it confers no degree. It is important to note that since FMGs are only needed by the US to fill the market demand as and when it crops up; FMG intake is subject to capricious movements of US policy.

Mr. Azad’s target group:

The Indian doctor with an MBBS or MD, who wants to train in a US residency program. Not students who go to medical school in the US. The India Ink article(linked above), erred in reporting this. It must needs be highlighted, that the Minister makes no distinction between graduates of government medical colleges (subsidized fee structure paid for by the public) and private medical colleges (higher tuitions paid for by the student alone).

THE ISSUES:

1.Is this stipulation specifically for US bound doctors only?

Yes. The GOI initiative stems from a US demand for an NOC. Doctors who wish to study in Australia, UK, NZ, Russia, China – anyplace but the US – are not subject to this rule.

2. Can the GOI be blamed for this policy initiative?

Not really. Since they clarify that the need for the NOC initiated from the US. Having said that; it is impossible to ignore GOI’s ill concealed schadenfraude at the possibility of waving the Damocletian threat of ‘retracting the NOC with subsequent denial of a US work permit’ if a doctor fails to comply.

3. Is the GOI justified in expecting doctors to return?

Yes. But, only the return of those doctors whose medical education it paid for. To elaborate and in all fairness, GOI has a legitimate expectation in demanding a return on its investment. The cost to the government for training doctors to serve society is enormous. Government medical students get excellent training for a pittance. For those that protest the use of that adjective: this is a good time to remind yourselves that a lot of medical training is clinical exposure to patients. And government hospitals afford an unmatched breadth of experience in this regard. A more demanding public would have insisted on a return on their tax Rupees long back. Socialism is not a one way street. A student who has availed of the government subsidy to finance his education cannot have a reasonable objection if the government expects him to serve (for a limited time period) the society that paid for his education. This reasoning will not be lost on ‘more progressive’ societies, such as the US, where discussions abound on issues of far lesser import, for e.g., on whether people who rely on food stamps can exercise the right to buy food of their choice. Or on where insurance companies can pay based on pre-conditions.

4. Is it a bond? Is it an affidavit without a bond?

I don’t know. The minister did use the word ‘ bond’. Bonds usually have conditional guarantees on freedom. Such as, a fine. Or community service for a period. In any case, why is there so much hyper-reaction to a bond, when many missionary medical institutions such as St. John’s in Bangalore and CMC in Vellore already have such conditional enforcement. And btw, yes, you can buy your freedom too.

5. Did the GOI or MOH say that this initiative was aimed at reversing a ‘brain-drain’ or at leveling the demand for doctors?

NO. This is simply the interpretation of the media. And a wrong one at that! It is obvious to anyone (and that is *anyone), working in health and allied services in India, let alone the GOI, that this reasoning is plain daft. Of everyone invested in India, GOI knows first hand, the extreme challenges faced by medical education and health. A brain-drain is the least of them. If there are contrary opinions flying around, they are just reactions to the misinterpretations. GOI or its minister said nothing of the sort. GOI’s intent is simply to collect a return on its investment. That’s it. And that is an immensely fair intention. They erred in not stating that this was specifically for doctors that trained in government medical colleges.

6. And finally, why do doctors migrate?

The media focuses on money. Of course, it is the money but it is not all of it. To conclude that way and expand on it is reductionism and intellectual laziness. Fact is, doctors in private practice in India also receive a handsome remuneration. Factor in family and cultural proclivities and many would choose to stay. Most obviously do. But since we are talking about those who leave, they have reasons other than money too: 1) Professional success – the technology, quality of training and standards are undoubtedly superior. Every professional has the ambition to succeed amongst the very best 2) A more equal environment – the Indian environment is unbearably patriarchal, nepotistic and sycophantic. Hindi has a better term for it, Mai-baap. Meritocracy is not rewarded; Servitude is. Many yearn to escape this system 3) Research and publishing opportunities and, 4) Prudent commonsense – In the competitive environment of his native land, a returnee armed with a foreign degree, will always have an edge.

To say that healthcare in India is in need of urgent reform is a tired rehashing of a ridiculously obvious cliché. But, say it we must. Even if it feels like an ad-hominem attack on our collective intellect. And act on it, we will have to. When we do, will it be a comprehensive and holistic attempt at results. Or will it be yet another firefighting exercise in a public health crisis. The fate of our lives will tell.